331880544-7-28-2023-18-AS-RSTS-CZN2Z6-20240119164948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880544
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:22:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221011122601

FACILITY NAME:	ANGELA'S CARE HOME		FACILITY NUMBER:	331880544
ADMINISTRATOR:	ANGELA ZHANG		FACILITY TYPE:	740
ADDRESS:	13247 SUNBIRD DR		TELEPHONE:	(951) 653-0652
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92553
CAPACITY:	6	CENSUS: 6	DATE:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Angela Zhang, Licensee/Adminstrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident received multiple pressure injuries while in care
Administrator did not properly assess resident for a level of care rate change

INVESTIGATION FINDINGS:

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Licensing Program Analsyt (LPA) Jesse Gardner and Licensing Program Manager (LPM) Joel Esquivel met with Licensee Angela Zhang at the CCL ASC Riverside Regional Office to deliver findings of the complaint.

Allegation: Administrator did not properly assess resident for a level of care rate change.
It was alleged that Resident #1 (R1) had several presure injuries upon admission; R1 had one pressure injury on their coccyx area and one on the right and left "sides". Interview was conducted with Licensee who stated that R1 was admitted to the facility with multiple pressure injuries. Based on the fact that the Licensee could not prove that the resident had a proper wound care plan, an assessment by the facility and that proper training was provided to staff, this allegation is thereby substantiated.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221011122601

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELA'S CARE HOME	FACILITY NUMBER: 331880544
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/04/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review the regulation, and provide proof of in-service training provided to Licensee and staff.
	8 9 10 11 12 13 14	Based on interview with Licensee, Resident was admitted to the facility with pressure injuries, without an assessment. Staff were alleged to have been caring for R1; however, the Licensee admitted that R1 had eventually moved to skilled nursing due to the inability to care for R1's wounds. This poses an immediate health and safety and/or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 08/04/2023 Section Cited CCR 87458(a)	1 2 3 4 5 6 7	Medical Assessments: (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit a plan to improve intake assessments, and submit that plan by POC date. Additionally, Licensee agrees to review the regulation, and provide proof of in-service training provided to Licensee and staff.
	8 9 10 11 12 13 14	Based on interview with Licensee, R1 was not offered a proper assessment upon admission to the facility. Licensee understood that R1's pressure injuries got worse under her care. Licensee indicated that R1 was turned every 2-3 hours, but the wound to her coccyx got larger. Even though R1 was allegedly to have been assessed, Licensee does not have documentation to prove that it did. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20221011122601

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ANGELA'S CARE HOME	FACILITY NUMBER: 331880544
	VISIT DATE: 07/28/2023

NARRATIVE

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When asked if the resident had been assessed upon admission, Licensee stated that she did not have any type of documents that showed the assessment had been completed. LPA requested a care plan for R1 showing that wound care was being provided as required and that training was provided to the staff regarding said wound care. As such it would be reasonable to assume that the Licensee did not conduct an assessment and training was not provided to staff for the care of the resident's pressure injuries. Licensee had the resident relocated to another facility. The facility had the resident transferred to a skilled nursing facility immediately after admittance due to the need for a higher level of care and the multiple pressure injuries.

Based on the fact that the Licensee was unable to provide a proper assessment made by the licensee/ Administrator, and the facility did not have a documented wound care plan for R1, the allegation was Substantiated. Facility cited.

An exit interview was conducted where a copy of this report was discussed with Zhang and copies of the LIC9099D and Appeal rights were given.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

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